HospitalInspections.org

Based on review of credential files, review of Medical Staff Bylaws and staff interview, the CAH (Critical Access Hospital) failed to follow the Medical Staff Bylaws in the reappointment of 6 of 8 sampled physician/non-physician credential files reviewed (Physicians C, D, E, F, G and H) by not ensuring that granting of privileges was based on continued qualifications as spelled out in the Medical Staff Bylaws. This failed practice has the potential to affect all patients of the hospital. The list of physicians/non-physicians on the medical staff (no date) provided by the Administrator listed 2 active staff (practitioners who admit patients to the hospital), 40 consulting practitioners (practitioners who are recognized specialists willing to serve in a consulting capacity), 15 courtesy practitioners (practitioners who only occasionally admit or see patients at the hospital) and 3 affiliate staff (advanced practice registered nurses and physician's assistants).

Findings are:

A. Review of the Medical Staff Bylaws approved by the Governing Board on 6/1/09 revealed the following under Article VI Procedure for Appointment and Reappointment, Section C Reappointment Process:
"Each recommendation concerning the reappointment of a Medical Staff member, and the clinic privileges to be granted, upon reappointment, shall be based upon such member's professional competence and clinical judgement in the treatment of patients, his ethics and conduct, his attendance at Medical Staff meetings and participation in staff affairs, his compliance with the hospital Bylaws, Rules and Regulations, his cooperation with hospital personnel, his use of the hospital's facilities for his patients, his relations with other practitioners, and his general attitude toward patients...."

B. Review of Physician C's credential file (last reappointment by Governing Board 9/16/14); Physician D's credential file (last reappointment by Governing Board 1/14); Physician E's credential file (last reappointment by Governing Board 5/13); Physician F's credential file (last reappointment by Governing Board 10/28/14; Physician G's credential file (last reappointment by Governing Board 9/13); and Physician H's credential file (last reappointment by Governing Board 12/16/14); revealed no information in regards to:
- professional competence and clinical judgement in treatment of patients;
- ethics and conduct;
- attendance at Medical Staff meetings (if applicable) and participation in staff affairs;
- compliance with the hospital Bylaws, Rules and Regulations;
- cooperation with hospital personnel; and,
- use of the hospital's facilities for patients.

(A physician credential file contains the information gathered at the time of appointment/reappointment to the hospital medical staff and includes information such as: an application; list of privileges requested; verifications of education, training, work experience, licenses, registrations and references; background checks; and, activity and quality at the CAH.)

C. Interview with the Administrator on 2/18/15 at 2:30 PM confirmed the lack of documentation regarding these 6 physicians at the time of reappointment.

Based on medical record review, review of policy and procedures and staff interview, the CAH (Critical Access Hospital) failed to ensure that the physicians completed and documented their examinations of the patients immediately before surgery to evaluate the risk of the procedure to be performed for 5 of 6 discharged surgical patient records (Patients 26, 27, 28, 30 and 31) reviewed. This failed practice had the potential to affect all surgical patients of the CAH. Total procedures/surgeries performed for the fiscal year July 1, 2013- June 30, 2014 was 487.

Findings are:

A. Review of Patient 26's medical record revealed the patient had a tonsillectomy (removal of the tonsils) done under general anesthesia (medically induced coma for surgery) on 8/7/14. Patient 26's medical record lacked evidence of a documented patient examination by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

B. Review of Patient 27's medical record revealed the patient had a cholecystectomy (removal of the gallbladder) done under general anesthesia on 9/3/14. Patient 27's medical record lacked evidence of a documented patient examination by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

C. Review of Patient 28's medical record revealed the patient had a cystoscopy (scope used to examine the bladder) done under general anesthesia on 9/11/14. Patient 28's medical record lacked evidence of a documented patient examination by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

D. Review of Patient 30's medical record revealed the patient had a transurethral incision of the prostate (through a scope passed through the penis an incision is made in the enlarged prostate to increase the urine flow out of the bladder) done under general anesthesia on 2/5/15. Patient 30's medical record lacked evidence of a documented patient examination by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

E. Review of Patient 31's medical record revealed the patient had an upper gastrointestinal endoscopy (a scope passed through the mouth to visualize the throat, stomach and the beginning of the small intestine) done under MAC ([monitored anesthesia care] using intravenous conscious sedation to promote relaxation and amnesia types of anesthesia) on 1/14/15. Patient 31's medical record lacked evidence of a documented patient examination by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

F. Review of Policy and Procedure titled Pre and Post Anesthesia Evaluation dated 8/15/11 revealed, "Documentation of the evaluation of the patient immediately prior to surgery by anesthesia and surgeon is verified..."

G. Interview with the CRNA (Certified Registered Nurse Anesthetist)/Surgery Supervisor on 2/25/15 at 2:30 PM confirmed the lack of physician examination immediately before surgery for (Patients 26, 27, 28, 30 and 31).